PA Peterson at the Citadel

    1311 Parkview Ave, Rockford, IL, 61107
    • Independent living
    • Assisted living
    • Memory care
    • Skilled nursing
    AnonymousLoved one of resident
    2.0

    Compassionate rehab but neglectful care

    I had a very mixed experience. The rehab/therapy team and several nurses (Sherri, some RNs) were compassionate and got my loved one stronger - beautiful grounds, golf-course view, lots of activities, and a pleasant neighborhood. But the building is dated and poorly maintained (peeling wallpaper, broken elevator, mold, pests, urine odor), food and housekeeping were inconsistent, and management often unresponsive. Worse, chronic understaffing and slow call-light responses led to neglectful care and at least one unsafe transfer that resulted in a broken leg; I witnessed long waits for help and alarmingly poor hygiene for some residents. Staff quality is hit-or-miss-some attentive professionals, some rude/untrained aides-so I'd only recommend this for short-term rehab if you plan to be very involved; otherwise, take your loved one home and hire private care.

    Pricing

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Restaurant-style dining
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (non-medical)

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    3.17 · 133 reviews

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      3.0
    • Staff

      3.1
    • Meals

      2.3
    • Amenities

      2.8
    • Value

      2.3

    Pros

    • Many staff described as compassionate, attentive, and nurturing
    • Dedicated nurses and several praised CNAs and rehab staff
    • Strong physical and occupational therapy / successful rehab outcomes
    • Some social work and discharge planning highly effective
    • Clean, comfortable private rooms reported by multiple reviewers
    • Family-friendly areas and outside balcony / pleasant grounds
    • Scenic location across from a golf course and safe neighborhood
    • Engaging activities and outings (puzzles, games, karaoke, water aerobics)
    • Salon access and on-site services available
    • Secure entry with buzzer and sign-in procedures
    • Some consistent reports of good, home-like meals and snacks
    • Helpful front desk and reception staff in many accounts
    • Ability to transition residents home after rehab
    • Some reviewers reported good value relative to local options
    • Positive experiences reported after new management / renovations by some

    Cons

    • Highly inconsistent care quality across shifts and staff
    • Chronic understaffing and overworked staff reported frequently
    • Very slow or unresponsive call light / delayed help
    • Serious hygiene and cleanliness problems in many reports
    • Recurring strong urine and other foul odors in hallways/rooms
    • Pest problems cited (roaches and mice on some floors)
    • Food quality highly variable — many complaints of poor/tasteless meals
    • Facility aging and maintenance issues (peeling wallpaper, broken molding)
    • Elevator failures and long-term out-of-service elevator reported
    • Laundry problems and missing or returned-inadequate clothing/belongings
    • Medication, diabetic care, and charting errors or delays alleged
    • Allegations of neglect and unsafe care (left on toilet, delayed assistance)
    • Serious safety incidents reported (falls, broken bones, infections, sepsis)
    • Management unresponsive, poor communication, and blame-shifting
    • Night and weekend coverage frequently worse than daytime
    • Reports of soiled linens, fecal contamination, and unsanitary supplies
    • Billing/insurance concerns and alleged double-charging accusations
    • Some reviewers report rude or disrespectful staff behavior
    • Hot water, A/C, and temperature-control failures on some floors
    • Dementia/Alzheimer's unit understaffed and safety concerns noted
    • High monthly cost noted by multiple reviewers (~$7,000 cited)
    • Mixed reports on activities and programming availability
    • Infection outbreaks and multiple IDPH calls alleged by reviewers

    Summary review

    Overall sentiment for PA Peterson at the Citadel is deeply polarized: reviews range from highly positive accounts praising compassionate staff, strong therapy services, and successful discharges to severe negative reports describing neglect, unsanitary conditions, and safety incidents. Many reviewers explicitly say the care team—nurses, therapists, social workers, and certain CNAs—provided excellent, family-centered support, got residents rehabilitated, and helped them return home. At the same time, a large number of reviews recount troubling systemic issues: understaffing, inconsistent caregiver performance, slow responses to call lights, and management unresponsiveness.

    Care quality and staffing form the central theme. Positive stories emphasize dedicated nurses and therapists (names like Sherri, Asia, and April were singled out), effective PT/OT leading to improved mobility and discharge home, and social services that navigated insurance and placement well. Multiple reviewers credit the facility with top-notch rehab and attentive wound or dialysis care. However, an equally large and troubling set of accounts describe CNAs and nurses who are inattentive, on their phones, fail to introduce themselves or read charts, and sometimes leave residents waiting for long periods—examples include residents left on toilets for 45 minutes to multiple hours, missed insulin or delayed blood sugar care, and missed or late meals. Night and weekend shifts are repeatedly called out as worse than daytime coverage.

    Facility condition and cleanliness are another major divide. Several reviewers describe clean, well-kept private rooms, renovated lobby areas, and pleasant grounds—many appreciate the scenic location by a golf course and accessible outdoor walking areas. But many other reviewers report serious maintenance and sanitation failures: peeling wallpaper, broken plastic molding, nailed-in cable, long-term out-of-service elevators (one report of a second elevator down for 4+ months), no hot water or failing A/C on floors, soiled carpets, fecal matter smeared on walls, soiled washcloths left on floors, filthy sinks storing medical equipment, and evidence of pests (roaches and mice). These accounts include alarming descriptions of odors (urine), mold, garbage in hallways, and overall “run down” or depressing interior spaces outside the renovated areas.

    Dining and nutrition are also inconsistent. Several reviewers find meals home-like and tasty, mention snacks like freshly made popcorn, and appreciate dietary accommodations. Conversely, many reviews complain of bland, salty, canned, or “dog food”-like meals, lack of diabetes-friendly options or missing insulin administration, cold food, and missing basic condiments (milk, sugar, salt/pepper). Some family members reported having to bring food daily to ensure their loved ones ate. Restricted diets and generic sugar-free drinks were also criticized.

    Safety, infection control, and medication management raise significant concerns for a portion of reviewers. There are multiple allegations of infection outbreaks (including COVID and C. difficile), reports of wound infections and sepsis, and claims of near-fatal incidents and neglect during medical emergencies. Several reviews detail falls and unsafe transfers (including one account of a broken leg following an unsafe transfer), medication left unattended, delayed or missed insulin and blood sugar checks, and accusations of elder abuse or gross negligence. While some residents received excellent clinical attention, the number and severity of safety complaints mean these issues should not be dismissed.

    Management, communication, and administrative issues further complicate impressions. Reviewers report inconsistent responsiveness from management and social services—phones often go unanswered, family communications are poor or delayed, and concerns are shifted or minimized by staff. There are split reports regarding the impact of new ownership or management changes: some reviewers feel improvements and renovations are underway, while others believe the facility declined after takeover, with staff morale and oversight suffering. Billing and insurance issues were raised by a few reviewers, including allegations of improper Medicare/Medicaid charging and pressure to discharge residents prematurely for insurance reasons.

    Activities, amenities, and value are mixed. Many residents enjoy a variety of activities, church services, outings, and social programming; others say activities were absent or minimal. Amenities such as a salon, secure entry, shuttle service, and therapy departments receive praise. Cost perceptions vary: one reviewer cited a high monthly cost (~$7,000) and some consider it expensive but worth it when care is good, while others view the price as unjustified given maintenance and quality concerns.

    In summary, the reviews portray PA Peterson at the Citadel as a facility with clear strengths—notably a strong rehab program, many caring clinical staff members, effective social work/discharge planning in numerous cases, and a pleasant location—but also with repeated, serious red flags around staffing consistency, sanitation, maintenance, safety, and management responsiveness. Experiences appear highly dependent on the unit, shift (nights/weekends worse), and specific staff on duty. Families considering this facility should weigh the polarized feedback carefully: verify current staffing levels and night/weekend coverage, tour multiple unit areas (not just the lobby and show rooms), ask directly about infection control history and recent inspections, confirm meal plans for dietary needs, request recent maintenance and elevator repair status, inquire about laundry and belongings policies, and get specifics about billing and discharge practices. Active family involvement and close monitoring appear to make a substantial difference in whether a resident's stay is positive or problematic according to these reviews.

    Location

    Map showing location of PA Peterson at the Citadel

    About PA Peterson at the Citadel

    PA Peterson at the Citadel sits at 1311 Parkview Ave in Rockford, Illinois, and offers a small, comfortable place for seniors who need skilled nursing or memory care, and you'll notice right away that the staff is always around, with board certified nurses and licensed caregivers there day and night, ready to help with daily needs or health issues. Folks living here get all meals provided, plus snacks, and they don't have to worry about chores because housekeeping, laundry, and building maintenance get done every week, and all utilities except the phone are covered, with basic satellite TV included and rooms pre-wired for both telephone and TV. Everyone can use the common rooms, walk the indoor and outdoor paths, visit the chapel, or join in activities like music therapy, pet visits, Bible study, yoga, exercises, and more, and there's even a beauty and barber shop, central dining room, fitness center, and modern kitchens.

    People can also go out to community events, local restaurants, and entertainment, and for folks who want spiritual services, there are offsite devotional options and a chapel onsite for Bible study and gatherings. PA Peterson provides a variety of short and long-term care services such as respite care for those recovering or giving a break to caregivers, hospice and palliative programs, and helps people stay independent with support as needed, with staff helping with medications and personal care. Special care is available for people with memory challenges, with secure areas and care plans to support memory and cognitive skills, and the nursing team can help with therapies like physical, occupational, speech, IV, cardiac, pulmonary, orthopedic, and stroke rehabilitation, plus dialysis. Residents who can't live by themselves can get long-term care with assistance for daily living, and the facility tries for a homelike feeling with peaceful, newly renovated areas and safety features like an emergency call system, big bathrooms with safety fixtures, sprinklers, cameras, and a secured environment, so people can feel safe while enjoying social events, meals, and programs with others, and it even has a bit of that hotel feel with spa-like design. Office hours are Monday to Friday from 8 in the morning to 5 in the evening, and the place is known for giving care that's both personal and clinical for a community atmosphere that tries to help folks be as healthy and happy as possible.

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